By Nick Rinard MPT, Cert MDT
24 Sep, 2026
Clinical Case of the Week
exercise, Low Back Pain, MDT, Motor Vehicle Accident, MVA, neck pain, Nick Rinard, Nick Rinard physical therapy, pain-free, Physical Therapy, Portland Oregon, results, treatment
If you’re still in pain more than 6 weeks after normal “healing” time for MVA trauma, it is not too late for physical therapy to help.
Why Can Pain Continue After Healing?
As you know from the last Clinical Conversation update, healing tissue begins forming and changing in the first several weeks after trauma. If pain and stiffness continue, the injured tissues may still benefit from further remodeling and appropriately dosed movement and loading.
How Physical Therapy Helps Remodel Tissue
Tight or painful tissue can continue to adapt over time through targeted, mechanical, dosed loading. Physical therapy uses specific exercises and hands-on techniques as needed to gradually improve mobility, tolerance to load, and function.
Could a Joint Derangement Be Contributing?
Another possible source of persistent pain after an MVA is an underlying mechanical problem that has not yet been identified. Our MDT method uses repeated movement testing and the patient’s response to help identify mechanical patterns, including joint derangements, and guide treatment toward movements that reduce symptoms and improve function.
So, even if your accident happened months ago and your body has already gone through its initial healing process, it is not too late for physical therapy.
Come to Nick Rinard Physical Therapy to determine whether restricted tissue, a mechanical joint problem, or another musculoskeletal issue may still be contributing to your lasting pain.
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Same pain experience. Totally different cause. Totally different treatment.
Both patients were extremely happy with their results!
Written by Nick Rinard, PT, MPT, Cert. MDT
Two patients today. Both complaining of the same type of knee pain and similar weakness. Both were limited deep squat/crouching functions and both had difficulty getting up from the floor. Despite the patients’ similar knee experience, the mechanical evaluations and subsequent diagnoses were totally different!
It is important that your physical therapist understand how to rule in and rule out various known causes of knee pain and treat the different causes of knee pain differently. There are way too many generic knee programs out there that do not match the correct diagnosis and are therefore either ineffective, or cause additional damage.
Same Symptoms, Different Causes
Patient 1 had loss of knee motion, weak hamstrings, and no loss of spine motion.
Patient 2 had no loss of knee motion, weak quadriceps, and loss of spine motion.
When testing patient 1, repeated spinal motions had no effect on knee findings, but repeated knee extension cleared up a majority of knee findings when re-tested. Specifically, deep squat was better and they were no longer weak when testing resisted hamstrings, nor had any loss of knee ROM! It was important to rule out the spine first, then move on to knee.
In contrast, patient 2 responded immediately to repeated spinal extension, which centralized knee pain to then spine, and resulted in much improved deep squat and stronger quads afterwards! In this case, the knee pain was coming from the spine, so it was good to not miss that!
Why the Right Diagnosis Matters
PLEASE make sure your physical therapist is aware that all potential causes of your pain must be ruled in or out in order to give you the matching treatment. If you are not seeing results within 3-4 visits, it is highly likely the P.T. has missed the correct mechanical diagnosis and is not treating the cause.
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By Erick Severo
20 Jul, 2026
Clinical Case of the Week
exercise, hip, knee, MDT, Nick Rinard, Nick Rinard physical therapy, pain, pain-free, Physical Therapy, Portland Oregon, post-op, prehab, rehab, results, shoulder, Surgery, treatment
This article was written by Danya Sadler, Student Physical Therapist, during her clinical rotation at Nick Rinard Physical Therapy.
What is Prehab?
Many people assume that physical therapy begins only after surgery, but postoperative rehabilitation is just one part of what physical therapists do. The American College of Surgeons defines prehabilitation, or “prehab,” as “a process of improving the functional capability of a patient prior to a surgical procedure so the patient can withstand postoperative inactivity and the associated decline.” Physical therapists accomplish this through targeted exercise, education, and movement strategies tailored to each individual.
What the Research Shows
Prehab is much more than simply “getting ready” for surgery, it gives patients the opportunity to improve strength, mobility, and confidence while working toward their best possible outcome. A growing body of research has shown that prehab is an effective way to make the most of that opportunity. A research article by Konnyu, et al. finds that prehab prior to total knee or total hip surgeries can lead to reduced length of stay in the hospital, increased strength, and decreased stiffness post-operatively. Another article looking at orthopedic surgeries found that “prehabilitation was associated with moderate improvement in several preoperative outcomes (function, 6-minute walk test, knee flexor and hip abductor strength, etc.) among patients undergoing all orthopedic procedures and was also associated with a reduction in back pain among patients undergoing lumbar surgery.” (Punnoose et al., 2023). The research behind this topic has been vastly growing over the years but all other articles shared similar findings. In some cases, the prehab process reveals something patients weren’t expecting: surgery may not be the right next step after all.
When Physical Therapy May Help Avoid Surgery
For many musculoskeletal conditions, current evidence supports physical therapy as a first-line treatment for many musculoskeletal conditions before considering surgery, as many patients achieve similar improvements in pain and function without an operation. This is not to say that surgeries are bad nor never warranted, because they are actually very well researched and helpful in many cases. By using physical therapy first however can help patients find a potential non-surgical way of improving function and reducing pain, or, if symptoms persist despite appropriate rehabilitation, physical therapy can help patients and their healthcare team determine that surgery is the most appropriate next step. Multiple randomized control trials and systemic reviews comparing supervised exercise therapy with arthroscopic surgery for degenerative meniscal tears have found similar improvements in pain and function, while the physical therapy group demonstrated greater improvements in muscle strength early in rehabilitation.
A Closer Look at Low Back Pain
Evidence supporting conservative care extends beyond meniscal injuries. Similar recommendations exist for conditions such as knee osteoarthritis, rotator cuff injuries, and more but I want to present some evidence about its use with patients with low back pain since we see many individuals with this at the clinic. While surgery for back pain is appropriate in certain conditions like progressive neurological deficits or required fusions, most episodes of low back pain improve with conservative care. Current clinical practice guidelines from JOSPT and the American College of Physicians recommend remaining active, participating in exercise-based rehab, and working with a physical therapist before considering surgical intervention when there are no red flags found by your clinician or your physical therapist. Physical therapy can decrease pain, improve mobility, increase strength, and also help patients return to their daily activities while determining whether surgery is truly necessary.
The Right Treatment at the Right Time
Ultimately, the goal of prehab isn’t to avoid surgery at all costs, it is to ensure that each patient receives the right treatment at the right time whether it be surgery on conservative care. If surgery is found to be the best next step, patients will benefit from becoming stronger, more informed, and more active participants in their own care.
Citations
American College of Surgeons. (n.d.). Prehabilitation. Strong for Surgery. Retrieved July 8, 2026, from https://www.facs.org/for-patients/preparing-for-surgery/strong-for-surgery/prehabilitation/
Konnyu KJ, Thoma LM, Cao W, Aaron RK, Panagiotou OA, Bhuma MR, Adam GP, Pinto D, Balk EM. Prehabilitation for Total Knee or Total Hip Arthroplasty: A Systematic Review. Am J Phys Med Rehabil. 2023 Jan 1;102(1):1-10. doi: 10.1097/PHM.0000000000002006. Epub 2022 Mar 12. PMID: 35302954; PMCID: PMC9464791.
Punnoose A, Claydon-Mueller LS, Weiss O, Zhang J, Rushton A, Khanduja V. Prehabilitation for Patients Undergoing Orthopedic Surgery: A Systematic Review and Meta-analysis. JAMA Netw Open. 2023;6(4). doi:10.1001/jamanetworkopen.2023.8050
Kise N J, Risberg M A, Stensrud S, Ranstam J, Engebretsen L, Roos E M et al. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up BMJ 2016; 354 doi:10.1136/bmj.i3740
Qaseem A, et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians. Annals of Internal Medicine. 2017;166(7):514–530.
George, S. Z., Fritz, J. M., Silfies, S. P., Schneider, M. J., Beneciuk, J. M., Lentz, T. A., Gilliam, J. R., Hendren, S., Norman, K. S., et al. (2021). Interventions for the management of acute and chronic low back pain: Revision 2021. Journal of Orthopaedic & Sports Physical Therapy, 51(11), CPG1–CPG60. https://doi.org/10.2519/jospt.2021.0304
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By Erick Severo
16 Jun, 2026
Clinical Case of the Week
exercise, MDT, Nick Rinard, Nick Rinard physical therapy, pain, pain-free, Physical Therapy, Portland Oregon, results, treatment
Written by: Danya Sadler, SPT
When Rib Pain Isn’t What It Seems
We had a patient this past week with a unique challenge. This patient had been fighting with a serious medical condition for the past couple months and had, a week before seeing us, started experiencing pain on their left lower ribs. This patient had great difficulty sleeping, rolling over, and generally moving around and wanted to see if this new symptom was related to the illness or if it had a mechanical component.
This visit was conducted via telehealth which is a great way for patients to be seen who either are living or travelling far away or people, like our patient in this article, who are homebound due to their illness or injury. This patient was told at the start of the visit that we were going to use this first visit to determine if there was a mechanical component to their rib pain and if there wasn’t, that we were going to help guide them to appropriate medical providers for further evaluation.
Using Movement to Find Answers
During this visit, it was difficult to conclude whether the rib pain was mechanical or visceral. The patient had tenderness around their left lower ribs, but also had right sided tenderness right underneath the ribs dealing more with internal structures. One notable finding was the patient experienced some pain relief when side-gliding to the right and side-bending to the right. Based on this response, we decided to have the patient perform these consistently over the next few days to see if this would relieve symptoms and help us conclude if this rib pain was indeed mechanically based.
An Unexpected Setback—and a Breakthrough
When we followed up with the patient a few days later, they reported an eventful week. Shortly after our initial evaluation, they went to the emergency room with severe rib pain and did not do their PT exercises at all. After testing negative for any illness related cause of her rib pain, she went home and then began performing the assigned movements consistently. They worked! The patient was happy to report that their pain had almost completely gone away! They were very grateful that we were able to provide the tools to reduce their pain and gave them hope even in these really difficult times that they were facing with their illness.
The Power of a Thorough Assessment
This case highlights the value of a thorough physical therapy evaluation, even when symptoms occur alongside a significant medical condition. Rather than making assumptions about the source of the patient’s pain, we used movement testing and symptom response to guide our clinical decision-making and determine the most appropriate next steps. By the patient’s second visit, their rib pain had improved dramatically, allowing them to move, sleep, and function more comfortably. Just as importantly, the patient gained confidence and clarity during a challenging time in their health journey.
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“I was referred to Nick by my orthopedic specialist because I was suffering extreme arthritic neck pain, which greatly limited my mobility and caused debilitating headaches.
My outcome after 4 visits…
– I know how to quickly get rid of my now, very rare, headaches
– My neck feels normal again. Range of motion is back and it’s moving without pain.
Thank you Nick! For creating such a warm and caring atmosphere. AND sharing your knowledge to help me get better. And the laughs!
Thank you Kari ! For your massages, tips and beautiful smiles.
I recommend your practice to all!”
Jennifer
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Patient who came in right away after injury only needed 3 visits!!
“I came in with a golf injury of unknown origin.
Nick was instrumental in helping figuring out the best way to rehab and recover.
I can’t thank him & the team enough for their help!”
Parker
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“I had continual cervical pain related to a motor vehicle accident.
The pain affected my ability to sleep, read, work, drive, watch tv, and turn my head without pain.
Now, I can do all the above activities and recreational sport activities.”
John
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“I came to Nick Rinard with back and leg pain that not being addressed by my current healthcare provider (because the current provider had no openings for PT).
I chose Nick Rinard because I had had a good experience there for an unrelated problem in the past.
Nick discussed my problems, possible PT options, “fixes,” & a strategy for exploring the options.
We tried a couple of alternatives & settled on a path.
I am happy with the results especially the pain reductions.
I felt Nick wasn’t me to have a positive outcome & kept me fully informed regarding why we were doing what we were doing, what he expected & importantly when he thought we had made all the progress we would make.
I am very happy that I came & would certainly do it again.
PS I paid for the treatments myself & regard it as money very well spent.”
James
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Thank you Troy for sharing your Nick Rinard Physical Therapy experience on google.
“As a competitive weightlifter, the pain in my back was seriously stalling my training.
Nick really listened and understood my goals and my issues and helped me get rid of the pain I’d been dealing with for over 6 months with only 2 visits and some assigned stretches.
I couldn’t believe it!
I’d seen doctors and other PTs and was about to get an MRI so I could get cortisone shots which was going to take months and only mask the pain if it solved it at all.
My experience was THE BEST.”
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Medication, surgery and physical therapy.
Out of the 3 – Physical Therapy is the first road to take.
- Surgery is not a cure all when it comes to back pain.
- Physical therapy restores movement, function and quality of life.
- Physical therapy is cost saving over medications and surgery.
- Injuries heal quicker with physical therapy.
- Medications are just a quick fix.
- Over the counter medicines have negative consequences with long term use.
- Physical therapy helps manage chronic pain for life.
- Physical therapy manages the effects of arthritis.
- Physical therapy prevents joint pain and instabilities.
- No risk profile for physical therapy.
- Physical therapy is totally reversible and no toxicity.
- Physical therapy is the most organic holistic approach that exists.
- No unknown ingredients.
“Severe back pain/herniated disc.
PT allowed me to avoid cortisone injection or surgery.
Initial progress was spot on.
I owe a debt of gratitude to Nick.
Thank you!
I am fully recovered.”
Brian
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